Mr H. did us all a great service in providing a platform for directing HIStalk reader questions to the CommonWell alliance from Cerner and company. Yes, I know that only 60 percent of the panel responding to the questions actually works at Cerner, but my articles are too long already without listing the full membership of CommonWell. I hope you’ll forgive me if Brightree isn’t the first vendor that jumps to mind when I think about CommonWell.

Given the fact that CommonWell is not consistently spelled “Commonwell,” we need to be especially appreciative that Mr. H gave them publishing space. I’m only allowed to write this article because I named my company “Carebox” even though I’m still waiting for the first person not related to me to spell it that way rather than “CareBox.”

Now, if you’re reading this article (clearly you are) and you still didn’t read that one (and you’re not related to me), you need to do a better job prioritizing what parts of HIStalk you read. We’ll all wait for you here while you go read that piece.

The Alliance

CommonWell is an “alliance.” I’m pretty sure that was selected over “empire” in the tight balloting in the CommonWell name-calling subcommittee because of the whole “Star Wars” context. For those who slept through the relevant decades, the “Alliance” is what you call the good guys, and if you’re reading this article and never saw “Star Wars” (even if you’re related to me), you really need to work on overall life balance.

By the way, I’m not 100 percent sure they have a formal name-calling subcommittee at CommonWell and, yes, I’m aware that the term “name-calling” has other connotations that have little do with HIT (OK, maybe a little).

From the questions that appeared in that article and the comments building up afterwards, it appears that there’s a bit of debate among some readers of HIStalk as to whether this alliance really gets to wear the orange jumpsuits and fly the Y-wing fighters. I’m not interested in getting into that debate. However, given my recent self-appointment as the voice (representing nobody) of innovative (self-labeled) startup companies that are seeking to leverage consumer healthcare data in various applications and services, duty calls! Give me just a minute here to adjust my cape. OK, ready …

Is a Patient in HIT a Subordinate Clause of Their Provider?

The quote I want to focus on from the CommonWell article is this one:

A single connection to the CommonWell network will enable providers and the patients they serve to access to [sic] their health information at all those various systems and organizations and won’t require peer-to-peer contracting for each provider you need to reach.

I was busy doing my math homework when we were in English grammar class so I don’t know if “and the patients they serve” is actually a subordinate clause or not. I’ve got a sinking feeling, though, that the high-sounding “serving the patient” expression doesn’t change the fact that whoever wrote that sentence views patient access to their own data as “subordinate” to the healthcare IT vendors and their healthcare provider customers. And nobody can mistakenly think that the “you” in “each provider you need to reach” from the quote above, refers to the patient/consumer.

The Missing Patient Service

I went to the CommonWell services page and I couldn’t find the service whereby a patient can request a copy of their healthcare records from everyone on the CommonWell network.

Interestingly, the word “patient” appears seven times on that page. There is talk of how to “link patients across organizations” and “patient identification” and even “patient-authorized.” But as far as I understood, that all seemed to be in the context of how providers exchange information with each other behind the patient’s back.

In both the body of the article and the comments section, there was quite a bit of back-and-forth about payment models and how the revenue pie should be shared among CommonWell members (vendors), the doctors who contribute the data, and McKesson (the company that got picked to provide the service).

There were also some interesting analogies made to financial transactions. Indeed, I believe there is a whole world of “behind the consumers’ backs transactions” that take place across financial institutions and in other EDI contexts. But at the end of the day, as a consumer, I can get a (free) copy of all of my transactions from all of my financial providers. And I can use a service like mint.com to act on my behalf and make it easier and more valuable for me to do that.

I’m not saying that’s the ideal model, is consumer-centric enough, or (conversely) is directly/fully appropriate for healthcare. But it’s interesting to think about how it works relative to how things are intended to work – and not only in CommonWell – when it comes to healthcare networks.

Curiously, I don’t recall that there was a need for Congressional involvement in order to establish a National Banking Identity for everyone. If I want to establish a mechanism to transfer money from my checking account to my mutual fund account, I set that up and provide the authorizations. As far as I know, the mutual fund company and the bank aren’t part of an “alliance” that provides “identification and linking services” to make sure they correctly match my bank account with my mutual fund account so that they can move information about me between them once they get me to sign a consent form I don’t fully understand while I’m at the bank teller.

What’s Your National Photographer ID?

Given how tough it is to do patient matching (I have a little MPI experience and it really is pretty tough), I’m amazed that Instagram has manage to get as far as they have without a National Photographer ID. How come LinkedIn doesn’t need my National Employee ID and Facebook doesn’t need my National Social Being ID (or my National Annoying Communicator ID for WhatsApp?)

It seems that by some miracle, armed with nothing more than an e-mail address, I can securely and reliably authorize any sharing network I want about my most sensitive information. Oh, wait, there is one catch — I have to be a little involved in process.

If my mom and my wife want to share information about me without me being involved (scary thought) then I suppose they would indeed need some kind of ID and matching process to ensure they aren’t sharing information about someone else when they use their “record locator service” to access each other’s database of information about me. But if I have my information stored with each of them in my e-mail-keyed (and easily validated) account that I maintain with each of them (hey, it’s an analogy, relax) and I authorize the sharing, it doesn’t need an act of Congress to get the information flowing.

This is Not Just a CommonWell Issue

Now if it sounds like I was being disingenuous above about not taking sides on CommonWell while adjusting their Darth Vader helmets, that’s a mistake. As far as I can see, CommonWell is mostly providing a more practical and commercially effective model for what the US government said it wanted to do all along in terms of national health networks – with the usual vendor politics and dynamics in play, as is to be expected.

Whether it’s FHIR as per my previous article, CommonWell in this one, Epic openness debates, or evaluation of data interoperability strategic roadmaps, I think one of the litmus-test questions has to be something like this:

How does your (standard, service, alliance, network, system, strategy, roadmap) empower a consumer to exercise their HIPAA-mandated right to get an electronic copy of their healthcare data and share it with (family, caregivers, providers, research groups, pharmacist, clinic, employer, people who will pay them for it, whoever) whenever they want?

CommonWell may have a better answer to this question than most, but it isn’t shining through yet clearly enough for me in their article on HIStalk or on their web site.

Is that a question from the noble, bright, and good part of the Force? Not necessarily. It’s as self-serving as anything in the CommonWell materials or anything else. I have a smaller company than Cerner to try and make successful, so if anything (deliberately using that word a third time in this paragraph – and breaking the flow of the paragraph – again – so I can generate some loyalty from the commenter who critiqued my problematic writing style in my last article), I can afford to be even less altruistic.

In the interest of transparency, I’m working on a draft resolution for my upcoming board meeting to have our name-calling committee allow me to swap out “CEO/Founder” for “Emperor.” I’ll let you know how it goes.

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Currently there are "4 comments" on this Article:

Plenty of reasonable critiques to be made on CommonWell, like business model and how well the patient identification works, but this is the worst critique ever. Inferring that participating vendors don’t care about patients based on a grammar nitpick? Really? The author should also know that HIPAA doesn’t govern Instagram data and medical providers who pay claims fees DO have detailed access to their transactions from all the major claims networks I’ve ever seen. Rather see a critique from somebody who knows more about it than what it publicly available on the internet while jumping to senseless conclusions.

HIPAA says that consumers/patients have a right to an electronic copy of every medical record stored about them by any provider. Why is it “senseless” or contrary to HIPAA governance to expect that CommonWell would provide a software service whereby an authenticated application acting on behalf of a consumer/patient would get a copy of the consumer’s data from every CommonWell-participating system, just as their provider can with their authorization?

Not sure where I inferred that vendors participating in CommonWell don’t care about patients. What I did intend to infer is that the CommonWell approach to healthcare data interop (as I noted, they are not at all alone here – this approach was at the core of failed government-grant-funded HIEs, NwHIN, and similar) appears to be driven by the notion that said data interop is fundamentally about provider-to-provider (more accurately, provider-vendor-to-provider-vendor) exchange, with patients getting access through a participating provider’s vendor-supplied system.

Makes sense to me that a consortium of (primarily) EHR vendors would choose to see things a particular way, but most data networks in other domains that I am aware of, which similarly manage the secure, consumer-authorized flow of our data, don’t work that way. And I do indeed think that allows them to spend less time spinning cycles on the perceived “complexity” of patient identification and patient consent (both of which require nothing more than an e-mail address and a URL click in most other contexts – and I don’t believe HIPAA requires more than that – though happy if you can point out the part of it that I missed, and how patient portal access is HIPAA compliant in view of that).

I do think there are valid arguments that can be made about why healthcare data is different (i.e. not suitable for consumer-consumption without mediation, etc.) and thus should follow a different paradigm. I’ve founded a company based on the counter-arguments to those arguments, which I think are a lot stronger (and which I believe have inevitable momentum on their side) – but I’d like to believe I’m not so myopic that I can’t see both sides of the debate.

On the “sic” – I called out the typo in the quote because I didn’t introduce it (though there are no shortage of typos, as well as grammatical errors, in my articles – including this one – I’m a poor proofreader). I don’t think what I wrote can be fairly characterized as a critique based on a grammar nitpick – but you certainly don’t need to agree with me. Really!

Thanks for pointing out that HIPAA doesn’t govern Instagram! Made me a little sad because I’d love to have a government-backed right to get copies of every photo someone took that has me in it. Maybe the new congress can help…

I think sometimes it’s helpful to get perspectives from folks in the dark who are limited to publicly available information, but if you have non-public information about CommonWell that helps shed more light on the subject – would be great to learn from it.

Sorry you didn’t like the article (at the risk of yet another senseless conclusion based solely on publicly available information, I’m assuming your “worst critique ever” characterization means that you didn’t really like it very much). Thanks for taking the time to share your perspective, I appreciate it!

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